Under the radar, over the holiday week, the NEJM published a report on transfusion requirements in older adults who surgical hip repair. The main finding is that most patients, including the elderly and those at risk for cardiac complications of the procedure, don’t benefit from getting so many red blood cell transfusions as is commonly prescribed.

The study, funded by the NHLBI, involved more than 2000 adults over 50 years of age who underwent hip surgery. Overall the patients were quite elderly, with a mean age above 80 in each group. The trial included patients with heart disease and risk factors for cardiac complications. Participants were randomized to receive red blood cells if their hemoglobin fell to a level below one of either two thresholds: 10 or 8 gm/dl. What happened is that, at the time of discharge from the hospital and by 60 days after the procedure, the rates of death, coronary syndrome and other complications were the same.

An accompanying editorial weighs in on the study and conclusion, that a standard threshold for ordering transfusions in the context of major hip surgery might be lowered. Reducing transfusions would lower demands on the blood supply, lessen the costs of administering these infusions, and reduce complications from infected or otherwise-damaging pints.

The study is important because it bolsters the evidence that too many units of blood are administered routinely. Sometimes with good reason, busy surgeons recommend a threshold for what’s almost an automatic order that blood to be given. If there is such a threshold in a SICU (surgical ICU), operating room or elsewhere, this report suggests it’s often too high.

It would be better, for sure, if transfusions were ordered on a case-by-case basis, with input by a doctor who would assess each patient’s baseline level of hemoglobin and other relevant factors. For example, a patient who’s been anemic for years may tolerate a lower hemoglobin level than someone who’s never been anemic before, or whose lung function is marginal.

Still, the main take is that many patients undergoing surgery need less blood than their doctors realize, and that we can safely, overall, reduce the number of transfusions ordered for many patients, even in those who are older and with risk of heart disease.

What patients might do: if you’re going to have major surgery, talk with your doctor about whether you might need blood and how the surgeon will decide if you need blood or not, and how much. If you have a strong preference to avoid transfusion, let your doctor know about that and discuss how you might avoid getting unnecessary pints.

Like many New Yorkers, feminists?, hematologists and other people, I was saddened to learn yesterday of Geraldine Ferraro‘s death. The Depression-era born mother, attorney, criminal prosecutor, Congresswoman, 1984 Democratic VP-candidate and part-time neighbor to yours truly, succumbed to complications of multiple myeloma at the age of 75.

Abnormal plasma cells in a bone marrow sample said to be from a patient with myeloma (Wikimedia Commons). Plasma cells have nearly-round, eccentric nuclei and abundant cytoplasm (ES).

Myeloma is a cancer of plasma cells – specialized white blood cells (mature B lymphocytes) that make antibodies. Plasma cells normally develop in the bone marrow; they can exit into the bloodstream, which is why this condition is often called a tumor of the bone marrow or, occasionally, sometimes, as a leukemia. The term myeloma comes from Greek roots – muelo (which can refer to the bone marrow) and –oma, which in medical parlance has come to stand for a tumor and may derive from soma (body).

According to the NCI, over 20,000 North Americans receive a myeloma diagnosis, and approximately 10,000 die from the disorder each year. It tends to arise in older folks, and is slightly more prevalent in men than in women. According to the SEER data, in 2007 there were over 61,000 men and women in the U.S. alive with a history of this disease.

What’s notable to me, as a hematologist, about the former congresswoman is that she lived with myeloma for over 12 years: She survived with a disease for which there were few treatments available when she was on the Presidential ticket. This was partly due to luck – always a factor in cancer outcomes, as some cases are intrinsically more aggressive than others; partly due to her access to excellent doctors and good care; and, also, likely due to advances in myeloma treatment over the past two decades.

Some perspective: When I completed my fellowship in 1993, the median survival for someone with myeloma was less than 3 years. Starting around then, most specialists steered patients under the age of 65, and in some communities, older patients as well, toward autologous stem cell transplantation – an aggressive approach that’s been shown to prolong lives of patients in randomized studies. (For the record, I’ve never been convinced by those data.) More recently, old drugs like thalidomide and its fresher derivative, lenalidomide (Revlimid), along with new drugs like bortezomib (Velcade) have demonstrated efficacy in this disease.

In my opinion, what’s ahead for doctors caring for myeloma patients – and for the patients, even more so – in this next decade, is to see if these old and new pills might be better, less costly and less toxic than transplant-based treatment regimens.

A final thought on Ferraro’s care, is that it seems she benefited from the care of experts: hematologist-oncologists, transplant physicians and other specialists and subspecialists. With all the push now for more primary care doctors – who are indeed needed – her survival with what might have been a quickly terminal illness is a testament to the value of knowledgeable, well-trained physicians who keep up with developments in an evolving field.

As for the ceiling-breaking congresswoman, my thoughts are with her family now. She was a remarkable lady in many ways.

Yesterday I learned that Serena Williams, the tennis pro, has been treated for a pulmonary embolus. My husband found out this morning upon reading the newspaper. He wondered why this would happen to a strong, young, athletic woman.

Without delving into the private or specific aspects of her case:

A pulmonary embolism, or PE in doctor-speak, happens when a blood clot enters or forms in the blood supply to the lungs. It’s a serious condition, because when blood vessels in the lungs are compromised, the lung cells can’t deliver fresh oxygen to hemoglobin that would normally pass through in red blood cells. Symptoms sometimes but not always include shortness of breath, pain in the chest that’s sharp in quality, and fatigue. Usually the diagnosis is made by a scan, such as a VQ or a special kind of (spiral) CT.

tennis racket and ball (Wikimedia Commons)

Treatment includes a blood-thinner, usually for a period of months. At first, and depending on the severity of the circumstances, patients may benefit from oxygen treatment through a light face mask or by nasal prongs. In general, doctors monitor patients for a short time in a hospital, to make sure the clot doesn’t get worse and that they don’t need additional oxygen support, and that the anti-coagulant is working.

When patients get blood clots it’s usually because they have a genetic tendency combined with some situation that aggravates that disposition. For example, if someone is born with a deficiency in a protein – of which there are quite a few – that normally dissolves clots, they might feel fine throughout life and be unaware of their hypercoaguable state. But after a big surgery, or if they were immobilized and dehydrated on a long plane ride, that might lead to a clot formation.

Sometimes surgery or inflammation in an extremity, such as a leg, can dispose to clot formation. When a clot forms there, it’s called a deep venous thrombosis (DVT) and that can, especially if untreated, break off and move through the large veins, to the right side of the heart, and then enter the pulmonary artery and smaller vessel or vessels in the lung. In that case it’s a PE.

Pregnancy, in itself and especially in women with underlying clotting disorders, can dispose young women to a DVT or PE. The same is true for estrogen-containing medications including birth control. Smoking, too –

A short personal perspective is that I once cared for a woman who had a PE who was young and attractive. She had been on a long, international flight a few days before she came to the E.R. It took hours for her to get past triage, and I suspect that was because she looked so healthy. It turned out she had a huge clot in her lungs, and a complex clotting disorder.

If a person with a DVT or PE turns out to have a genetic disposition, it doesn’t mean they need life-long treatment with a blood thinner. Depending on the location, severity of the clot and the circumstances, treatment is given for weeks or months. But it can be helpful to know if you have a clotting disorder. Some patients take prophylactic, low-doses of blood thinners when they travel or after immobilizing surgery, like a hip replacement.

Here are some useful websites that provide information on blood clots:

A few years ago my family took a trip to China. Even before we arrived, I learned something about an unfamiliar health care culture. What I observed en route was that many of the older passengers on that long flight to Beijing were getting up from their seats and stretching. Not just once, but regularly and systematically – they were doing slow motion, isometric calisthenics on the airplane.

I took notice of their behavior first because it seemed a simple and inexpensive, albeit strange example of preventive medicine. Second, as a hematologist who cared for patients with blood clots upon traveling, I pondered the risks and benefits of their on-board exercises. Third, as a patient who’s had a blood clot, or deep venous thrombosis (DVT), I thought maybe I should follow their example.

Thrombophlebitis – the old term for DVT – happens when a vein (as opposed to an artery) gets clogged with platelets and fibrous proteins. These tend to develop in people who are immobilized – after a hip or spine surgery, for example, or during long, cramped trips in airplanes with little legroom. For this reason, long-distance travel (in any sort of vehicle – it could be a car or bus or a train) is a major risk factor.

Dehydration and some medications can exacerbate the risk of developing blood clots during travel, as can having some kinds of cancer. (Pancreatic cancer, prostate, ovarian cancer and other tumors in the pelvis are particularly troublesome in this regard.) Some people inherit an increased tendency to develop clots; in general these can be evaluated by blood tests.

Most often DVTs arise in the legs but sometimes these also occur in the arms and other body parts. The condition can cause discomfort, pain, redness and swelling of an affected limb. These clots are most dangerous, and potentially lethal, if they spread to the lung – what’s called a pulmonary embolism. So there’s good reason to avoid these as best you can.

Here’s a list of some precautions to avoid blood clots when traveling:

1. Try to get an aisle seat. This strategy allows you to periodically stretch your legs into the aisle, and to get up without disturbing others.

2. While seated, move your feet and legs around as much as circumstances permit, and at least every hour or so. If you absolutely must remain seated, flex your feet 10 times, and stretch your legs as best you can, bending and extending the knees, one at a time, in any available direction, 10 times each. Another exercise is to raise each foot and swivel it, pivoting the toes from side to side while keeping the ankle relatively still.

3. Get up periodically and walk, every hour or two if permitted. (This means getting less sleep if you’re lucky enough to fall asleep, but I think the trade-off is worth it: being tired upon arrival is unpleasant; getting a blood clot is worse than that.)

If you’re on an airplane – once you’re up and out of your seat, seek out a place near the kitchen, restroom or elsewhere where you might stand. Then, hold onto the wall or the back of a chair, lift and stretch each of your legs repeatedly and then march in place: one knee up, then the next for two minutes or so, as conditions (and flight attendants) allow.

4. Stay well-hydrated by drinking ample water. Alcohol is a diuretic and should be avoided or minimized; caffeine too. Of course, for some travelers with weak bladders drinking lots of fluids can create a need for frequent bathroom trips. But this isn’t such a bad thing if you’re at risk for DVT, because this gets you up and out of your seat.

5. Dress sensibly – avoid tight clothing. (Some doctors recommend TED (thrombo-embolic Deterrent) or other compression stockings for patients with DVTs who travel, but I find these graduated compression nylons so uncomfortable that they reduce mobility, besides the capacity to bend and flex my ankles and knees.)

For women: avoid “knee-high” stockings with compression bands pressing just below the knees. These are a set-up for reduced blood flow from the lower legs to the larger, central veins.

6. Talk to your doctor if you’re concerned about DVT and are planning a trip. Ask about what precautions you might take in the context of your specific medical circumstances. Some people use heparin, a blood-thinner, or other medications while traveling to reduce their risk. Keep in mind that for most people, the risk of forming a significant blood clot is low.